Understanding Acopia, Aging, Adverse Drug Reactions, Polypharmacy And Its Impact On Elderly Patients

On successful completion of NUR341, you should be able to:
1. Demonstrate knowledge of the ageing process and associated complexities and relevant nursing care.
2. Demonstrate an awareness of personal, cultural and ethnicity attitudes and beliefs and how they affect nursing care.
3. Identify the range of services available to older people across the continuum of care.

4. Initiate and implement the nursing process to deliver appropriate, quality nursing care to older persons displaying different conditions and in a range of environments.
5. Examine comprehensive assessments of the older person
6. Assess the importance of the role of the nurse in the interdisciplinary approach to care planning and implementation of care. 

Classes for NUR341 are a mix of collaborate classes and pre-recorded lectures. There are no internal face-to-face lectures or tutorials in Semester 2, 2018.Collaborate classes (online) will be held Mondays, 1pm (Darwin time), in weeks in weeks 1,3, 5, 7, and 9. All collaborate sessions will be recorded and available a few hours after the live class. Please consider your individual time zone (and daylight savings where and when relevant) and convert as needed. There is also a handy tool on Learn line, on the top tool bar, that shows the current time in Darwin.

Your learning will be supplemented by pre-recorded lecture. A link for the lecture will be sent to your student email address in weeks 2, 4, 6, 8 and 10. Lectures are uploaded to YouTube so you can view on a range of devices at a time convenient to you.

Acopia and its impact on elderly patients

Acopia is usually a pejorative term, that is used to describe those people, who cannot cope up with the daily chores of life. Older patients are often triaged with the diagnosis of Acopia, on admission to the emergency department. According to the Australian studies, the term "acopia" is used for the patients who do not have significant acute health problems (Kee & Rippingale, 2018). Elizabeth is 87 years old and it is evident that she is undergoing the normal physiological processes of aging.

Aging that has taken a toll on her daily activities and so she has visited the hospital. The case study already reveals that the hospital is bed blocked, hence the patients who are having serious medical conditions have to be admitted in the hospital on a priority basis, than Elizabeth who is being diagnosed with Acopia. Although Acopia does not refer to any acute clinical condition, but it should be remembered that patients over 65 are presented with multiple long term complications, frailty and other functional and cognitive impairment (Oliver, 2008). If Elizabeth has to wait for 8+ hours in a trolley in the corridor, she might face problems regarding toileting or food intake. Furthermore, Elizabeth may also suffer from a fall if not supervised by a healthcare worker or professional. Hence elderly patients like Elizabeth who has poor functional reserve deserve to get better medical care.

question 2

Aging is mainly caused due to lifelong cellular damage and is caused by multiple mechanisms under the regulation of the complicated maintenance and repair framework. Due to this several physiological changes occur in the body (Kamaruzzaman, 2018).

The elderly people are more susceptible to pressure sores or ulcers due to prolonged sitting or any kind of immobilization for a prolonged period of time during the hospital stay. They are mainly caused due to the pressure exerted by the body weight and frictional rubbing of the skin. Generally, the elders are prone to develop pressure ulcers, as they have restricted mobility. The application of high pressure for the longer duration, not only does the necrosis of the tissues, but the blockage of the capillaries.

It also has a significant impact on the large vessels, causing thrombosis. With ageing the outer layer of the skin gets thin, although the number of the layers of the cells remains unchanged. The alteration in the connective tissue decreases the strength and the elasticity of the skin (Agrawal & Chauhan, 2012).

Aging and its physiological changes in the body

The skin loses the ability to retain the moisture and due to the less oil production by the sebaceous glands, due to which the skin becomes dry and itchy and fragile. Thus the skin is injured easily due to friction, rubbing or pulling. Furthermore, the layers of fat decrease with age, which increases the chance of pressure injuries. Wound healing is delayed due to the normal physiological processes of aging such as delays in the micro vascular responses (Agrawal & Chauhan, 2012). Elizabeth’s wait for long 8 hours in a trolley might increase pressure on certain areas of the back and can deteriorate the quality of experience of Elizabeth.

WA task Question 3

Adverse drug reactions (ADR) are common in elderly patients, as the older people are subjected to multiple comorbities and multiple prescriptions. The increased use of the number of prescribed drugs increases the risks of adverse drug interactions. Other range of factors includes altered drug pharmacokinetics profiles, pharmacodynamic responses and cognitive problem (Brahma, Wahlang,  Marak& Ch. Sangma, 2013). Many studies have suggested that ADR can also be caused in elderly patients, due to the medication errors of the clinicians. In this case study it can be seen, that Pradip is a 66 years old patient with multiple chronic diseases and multiple prescriptions making him vulnerable to adverse drug reaction.

According to studies the decreased capacity of the liver to process the drugs are one of the reasons for the adverse drug reactions, as they are not processed by the liver for their excretion from the body (Davies &O’Mahony, 2015). Furthermore, the decreased ability of the kidney to clear out the drugs from the body is another factor for the ADR in older adults. Other aspects of kidney functions also decrease with the age, which affects the drug filtration process. The physiological changes in the body due to aging (Less water retention and more fat), helps in the retention of certain drugs at a dangerously higher level. Most of the medicines that acts on the central nervous system such tranquilizers, sleeping, pills, and painkillers can harm the elderly patients even at normal levels which can be absolutely normal for the younger patients (Davies & O’Mahony, 2015).

Question 4

The case study already reveals, that the patient; Pradip was suffering from multiple chronic diseases and have multiple prescriptions. Polypharmacy is a growing problem for most of the elderly people. One of the risks of polypharmacy or multiple prescriptions is the adverse drug reaction. According to studies, about 4.3 million of the health care visits by the elderly have been attributed due to ADRs (Maher, Hanlon, &Hajjar, 2014). Another study has proven that the elderly patients who take more than 5-6 medicines are likely to be hospitalized due to adverse drug reactions. 

Adverse drug reactions in the elderly and its causes

Studies have also suggested that, patients who take more than 5-6 drugs are likely to face from potential cytochrome enzyme mediated and drug -drug interaction. Furthermore non adherence to the drugs has been found to be common in elderly patient with complex drug treatment regimen. Again non-adherence to medication can be related to treatment failure, rapid progression of the diseases, which can be life-threatening. Polypharmacy has been found to be associated with functional decline in the older adults. In a prospective study dealing with the community older adults, it has been found that increased prescribed medication is associated with low level of performing the instrumental activities of daily living (IADLs) (Alomar, 2014).

Urinary incontinence, cognitive impairment, falls and poor nutritional status has also been found to be associated with multiple medications.  Hence Pradip needs to consult a single physician and a single pharmacist, to avoid the lethal adverse drug reactions.  It is not known whether the conditions would improve but such an action would definitely reduce the chance of drug reactions.

Question 5

Poorly relieved pain in venous ulcer can be disturbing for any group of people and is a reason for the functional impairment in any age group. Especially, it can lead to functional impairment in the elderly people. Pain may lead to restricted mobility, sleeping disorder, slow rehabilitation, increased burden of health resources utilization and health care costs. However such factors in the elderly people can precipitate social isolation, which can lead to increased symptoms of cognitive impairment, anxiety and depression. The functional life of the elderly people can be greatly influenced by pain, as in most of the cases the pain is poorly managed in older patients (Salvetti et al., 2013).

According to the recent studies, pain can have a profound impact on the endocrine, cardiovascular, neurologic, and immune and the musculoskeletal system of the body. Any area of the body that will experience pain would soon be deconditioned. Presence of a single painful area in the body would cause the nerves, joints, and muscles somewhere in the body to compensate for the loss and thus works overtime. This chronic overload and overuse can lead to degeneration of the tissues at the secondary sites known as arthropathies, neuropathies and myopathies (Salvetti et al., 2013). Acute pain in venous ulcers can sometimes lead to tachycardia and hypertension.

This can be explained by the fact that excess glucocorticoids and the catecholamine are the contributory factors to these complications (Tennant, 2013). Lipid and insulin metabolism can be altered.  Pain in the venous ulcer patients can be persistent at the time of dressing change. Pain has been found to be affecting the quality of life and can affect the wound healing negatively. 

Polypharmacy and its impact on elderly patients

Question 6

The case study reveals that Arlinda is an elderly patient and older patient may face delayed healing of wound compared to that of the younger people. There are certain factors that come in to play in the process of wound healing, such as the types of the dressings used and the nutritional health of the person (Gould et al., 2015). There is certain age related physiological changes in Arlinda, which might have affected her wound healing process. One of the factors is the reduced elasticity of the skin. The skin loses its elasticity with age due to the degradation of the collagen and the elastic tissue. Hence older people possess a higher chance of scarring from a wound.

A Lower level of collagen can delay the process of wound healing, as it is needed for the cellular growth and tissue regeneration. Aging is also associated with delays in epithelialization, macrophage and T-cell infiltration. The age associated inflammation is featured by a high level of inflammatory cytokines and the growth factor .Due to this, the repair process is reduced to a considerate level. This inhibits the re-epithelialization.

With ageing, the capacity of the production of the extra-cellular matrix reduces. Furthermore, the hormonal status in the aged people can also delay the wound healing process. According to studies, the MMP2 are high in the older menopausal women (Gould et al., 2015). The vasoregulation of the aged skin is impaired that causes a change in the inflammatory response, less number of the progenitor cells and declination in the circulatory mediators. All these are associated with delayed wound healing in Arlinda.

Question 7

Pulmonary disease is common in the aged population. The intervertebral disk spaces narrow down with age, causing curvature of the spine, which decreases the space between the ribs leading to a smaller chest cavity. This affects the effectiveness of the intercostals muscles used in breathing. The muscle strength of the inspiratory and the expiratory muscles decreases with the age (van der Maarel?Wierink et al., 2013). This functional impairment of the respiratory muscles leads to inability to ventilate in presence of the increasing demand.

Patients with pneumonia are more likely to suffer from respiratory failure due to the increased metabolic demand and in a setting with decreased muscle strength (Lowery,  Brubaker, Kuhlmann& Kovacs, 2013). Normally lung possesses an immunologic defense that is both complex and resourceful utilizing both the innate and the adaptive immune response to the antigens. With ageing, there occur some important modifications in the innate immune response. The toll like receptors (TLRs) reduces with ageing. This affects the innate immunity of the elderly people, making them susceptible to infections. Due to this, the chance of pneumonia in the older people can be higher.

Impact of pain on elderly patients

With ageing there is a decreased ability to clear the mucus from the lungs. Two factors are responsible for this factor- The alteration in the ability of the body to clear the particles from the airways and reduced strength of the cough. Since the elderly people are frail that the younger people. They cannot clear the secretion from their lungs that can go down to the bronchial tubes giving rise to infection. Hence these are the predisposing factors to Pneumonia that can occur in Monty.

Question 8

Incidental exercises are activities that have to be done repeatedly throughout the day. Exercising is an important factor in losing cellulitis. In order to treat cellulitis, it is important to reduce the fat cells first, that can be accomplished through incidental exercises. There are studies, which prove that physical activities are likely to prevent cognitive decline among the older adults (Taylor, 2014).

Again incidental exercises can act as neuro-protective mechanism, to offer protection to the elderly from neurodegenerative diseases. Further, it has a positive influence over the respiratory, muscular and the circulatory system of the older adults. Physical activities are specifically important for those elderly people, who have a higher body mass index. Hence as a Registered Nurse, it is necessary to introduce incidental exercises in the clinical settings of acute wards (Binder, 2015).

Incidental exercises in an acute hospital care settings can be possible by incorporating the exercise regimen within the patient's chart. Simple exercises such as 30 minutes of walking assisted by the caregivers can be useful. If Monty has poor mobility, then he should be assisted with balance exercises to prevent falls. At least 100 minutes of moderate aerobic activities can be done. All the activities have to be done at an interval of 10 minutes (Sanchez-Lopez et al., 2018).The aerobic exercise should be at a moderate level that utilizes a large group of muscles. Exercises such as Tai- chi can be helpful for the patients. According to Sanchez-Lopez et al., (2018), a moderate level of incidental physical activities has been found to be useful for cardiovascular fitness.

References

Agrawal, K., & Chauhan, N. (2012). Pressure ulcers: Back to the basics. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 45(2), 244.

Alomar, M. J. (2014). Factors affecting the development of adverse drug reactions. Saudi Pharmaceutical Journal, 22(2), 83-94.

Binder, E. (2015). Frailty and Older Adults. In Exercise for Aging Adults (pp. 123-129). Springer, Cham.https://doi.org/10.1007/978-3-319-16095-5_10

Brahma, D. K., Wahlang, J. B., Marak, M. D., & Ch. Sangma, M. (2013). Adverse drug reactions in the elderly. Journal of Pharmacology &Pharmacotherapeutics, 4(2), 91–94. 

Davies, E. A., &O’Mahony, M. S. (2015). Adverse drug reactions in special populations – the elderly. British Journal of Clinical Pharmacology, 80(4), 796–807.

Gould, L., Abadir, P., Brem, H., Carter, M., Conner-Kerr, T., Davidson, J., …Schmader, K. (2015). Chronic Wound Repair and Healing in Older Adults: Current Status and Future Research. Journal of the American Geriatrics Society, 63(3), 427–438.

Kamaruzzaman, S. B. (2018). Frailty in Older People. In Geriatric Medicine (pp. 27-41). Springer, Singapore

Kee, Y. Y. K., &Rippingale, C. (2008). The prevalence and characteristic of patients with ‘acopia’. Age and ageing, 38(1), 103-105

Lowery, E. M., Brubaker, A. L., Kuhlmann, E., & Kovacs, E. J. (2013). The aging lung. Clinical Interventions in Aging, 8, 1489–1496. 

Maher, R. L., Hanlon, J. T., &Hajjar, E. R. (2014). Clinical Consequences of Polypharmacy in Elderly. Expert Opinion on Drug Safety, 13(1), 10.1517/14740338.2013.827660.

Oliver, D. (2008). “Acopia” and “social admission” are not diagnoses: why older people deserve better. Journal of the Royal Society of Medicine, 101(4), 168–174.

Salvetti, M. D. G., Costa, I. K. F., Dantas, D. V., Freitas, C. C. S. D., Vasconcelos, Q. L. D. D. A., & Torres, G. D. V. (2014). Prevalence of pain and associated factors in venous ulcer patients. RevistaDor, 15(1), 17-20

Sanchez-Lopez, J., Silva-Pereyra, J., Fernández, T., Alatorre-Cruz, G. C., Castro-Chavira, S. A., González-López, M., & Sánchez-Moguel, S. M. (2018). High levels of incidental physical activity are positively associated with cognition and EEG activity in aging. PloS one, 13(1), e0191561.

Taylor, D. (2014). Physical activity is medicine for older adults. Postgraduate Medical Journal, 90(1059), 26–32. https://doi.org/10.1136/postgradmedj-2012-131366

Tennant, F. (2013). The physiologic effects of pain on the endocrine system. Pain and therapy, 2(2), 75-86.

van der Maarel?Wierink, C. D., Vanobbergen, J. N., Bronkhorst, E. M., Schols, J. M., & de Baat, C. (2013). Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology, 30(1),